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Pain management
Pain, defined by International Association for the Study of Pain (IASP), as “an
unpleasant experience associated with actual or potential tissue damage to a
person's body”, is a very common presenting or accompanying symptom of
hospitalized patients. Pain management involves utilizing various modalities to
alleviate suffering and restore patient function. Proper assessment and treatment
of pain can improve clinical outcomes, discharge planning and patient and family
satisfaction. Pain management of inpatients necessitates understanding the
various mechanisms that cause pain, properties of analgesic pharmacological
and non-pharmacological modalities, as well as the accurate assessment of
severity and treatment response. Hospitalists assess and manage patients
experiencing pain. This role encompasses empathy, clinical excellence, and
understanding of the myriad obstacles, cautions and specific knowledge, skills
and attitudes necessary for appropriate pain management. Hospitalists serve as
leaders of multidisciplinary teams to develop policies and protocols to improve
pain management in their health care system.
KNOWLEDGE
Hospitalists should be able to:
• Describe the mechanisms that cause pain.
• Describe the symptoms and signs of pain.
• Differentiate acute, chronic, somatic, neuropathic, referred and visceral pain
syndromes.
• Differentiate tolerance, dependence, addiction and pseudo-addiction.
• Describe the value and limitations of the physical examination and various
validated pain intensity assessment scales.
• Explain the relationship between physical, cultural and psychological factors
and pain and pain thresholds.
• Discuss the genetic, social, and psychological factors that may contribute to
opioid addiction.
• Explain the indications and limitations of non-pharmacological methods of pain
control available in the inpatient setting.
• Explain the indications and limitations of non-opioids including acetaminophen,
nonsteroidal anti-inflammatory drugs (NSAIDs), and topical agents.
• Explain the indications and limitations of opioid pharmacotherapy.
• Explain the indications and limitations of other analgesics including, tramadol,
tricyclic agents and anti-epileptic medications in the treatment of various
pain syndromes.
• Describe specific factors that affect dosing regimes, such as drug half-life,
renal and hepatic function.
• Establish functional criteria for discharge.
Source:
(2006), Pain management. J. Hosp. Med., 1: 28–29. doi:10.1002/jhm.27
SKILLS
Hospitalists should be able to:
• Elicit a detailed history and description of pain and review the medical record to
determine likely source and acuity of pain.
• Review patient pharmacologic and psychosocial history and identify factors
contributing to pain or factors that might impact its management.
• Conduct a physical examination to determine the likely source of pain.
• Order and interpret diagnostic studies to determine the source of pain when
underlying acute illness is suspected.
• Assess pain severity using validated measurement tools.
• Formulate an initial pain management plan.
• Determine appropriate route, dosing and frequency for pharmacologic agents
based on patient-specific factors.
• Reassess pain severity and determine the need for escalating therapy and/or
adjuvant therapies.
• Determine equianalgesic dosing for pharmacologic therapy when needed.
• Titrate short and long acting narcotics to desired effect.
• Predict and counteract as needed expected analgesic side effects, including
use of reversal and specific agents, especially in elderly.
• Initiate appropriate therapies to prevent and treat constipation when using
opioid analgesics.
• Anticipate and manage side effects of pain medications including respiratory
depression and sedation, nausea, vomiting and pruritis.
• Assess and communicate need for pain management during medical
consultation.
ATTITUDES
Hospitalists should be able to:
• Promote the ethical imperative of frequent pain assessment and adequate
control.
• Appreciate that all pain is subjective and acknowledge patients' self-reports of
pain.
• Appreciate the value of patient controlled analgesia.
• Discuss with patients and families the goals for pain management strategies
and functional status, and set targets for pain control.
• Recognize indications for specialty consultation, which may include pain
service, anesthesiology, and physical and rehabilitation medicine.
• Employ a multidisciplinary approach to the assessment and management of
patients with pain that begins on admission and continues through all care
transitions.
• Educate patients and physicians on the importance of appropriate use of
opioids in pain management and explain the rarity of opioid addiction in
the setting of appropriate pain management.
• Establish and maintain an open dialogue with patients and families regarding
care goals and limitations, which may include palliative care and end-ofSource:
(2006), Pain management. J. Hosp. Med., 1: 28–29. doi:10.1002/jhm.27
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life wishes.
Address resuscitation status early during hospital stay; implement end-of-life
decisions by patient and/or family when indicated or desired.
Document treatment plan and discharge instructions, and communicate with
the outpatient clinician responsible for follow-up.
Provide and coordinate resources to patients to ensure safe transition from the
hospital to arranged follow-up care.
Utilize evidence based recommendations, including the World Health
Organization (WHO) step approach to pain management.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, Hospitalists should:
• Lead, coordinate, or participate in efforts to develop educational modules,
order sets, and/or pathways that facilitate effective pain management in
the hospital setting, with goals of improving outcomes and patient
satisfaction, decreasing length of stay, and reducing re-hospitalization
rates.
• Lead, coordinate or participate in efforts to measure quality of inpatient pain
control and operationalize system improvements and reduction of barriers
to adequate pain control
• Lead, coordinate or participate in efforts to establish or support existing
multidisciplinary pain control teams.
Source:
(2006), Pain management. J. Hosp. Med., 1: 28–29. doi:10.1002/jhm.27